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Why a Woman's Heart Disease Is Different From a Man's

From heart attack pain to statin prescriptions, what varies and why

Open packaging with statin tablets, with a stethoscope, and result analysis on cholesterol (lipid panel) and ECG

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En español | While science is only recently starting to understand why, his and her heart disease seem to follow very different scripts. From when blood pressure begins to rise, to where the pain of a heart attack is felt, to which medicines are — or aren't — prescribed, key differences between the sexes have emerged. Here's what to know.

Women experience heart attack pain differently than men do

As most people know, the sooner you recognize heart attack symptoms, the better, since your life can depend on getting to a hospital quickly.

In this area, women's heightened somatic awareness should give them an advantage, since it means they “feel pain sooner,” says C. Noel Bairey Merz, M.D., director of the Barbra Streisand Women's Heart Center at the Smidt Heart Institute at Cedars-Sinai Medical Center in Los Angeles. The catch? Women also feel pain less specifically.

That means that during a heart attack, women may feel pain in their neck, chest or arm — areas that may or may not set off the necessary warning bells that a potentially life-threatening event is underway. When women report such varied and diffuse pain symptoms, doctors often think they have the flu, says Bairey Merz. “Physicians are less likely to attribute their more generalized symptoms to their heart."

While men tend to feel more localized pain further into the stages of a heart attack, for either sex the proper diagnosis can hinge on which questions are posed. “Asking a patient if they have chest pain is a really close-ended question. Everyone's perception of pain is different,” says Nieca Goldberg, M.D.,senior advisor of Women's Health Study at New York University Langone Health in New York City. For this reason, instead of asking if a patient's pain is “like a knife,” Goldberg asks if they have the more general “chest discomfort.”

Women respond differently to a common heart-attack screening test at the hospital

Even if a doctor thinks a woman is having a heart attack, the event may not show up on a standard test that looks for proteins in the blood (called troponins) that are released when heart muscle is damaged. The heart-attack screening tool is not as specific in women as it is in men, says Bairey Merz. More sensitive troponin tests are currently being used in the U.K.; having one of these tests, according to recent research, boosted women's odds of getting a heart attack diagnosis by 42 percent.

Getting to the hospital quickly and getting the right diagnosis are only part of the challenge for women with heart disease. There is a huge difference in how men and women are treated following a heart attack, as many studies over the years have shown.

In a study published in the Journal of the American College of Cardiology last October, researchers at the University of Edinburgh found that women with the same cardiac diagnosis as men received only half the recommended treatments.

For example, of the 48,282 male and female patients with heart symptoms across 10 hospitals in Scotland, researchers found that 15 percent of women received a stent to open a blocked artery compared with 34 percent of men. Twenty-six percent of women versus 43 percent of men received clot-busting therapy and 16 percent of women received preventive treatment, such as cholesterol-lowering medication, known as statins, compared with 26 percent of men.

To make things more complicated, women are more likely to have a condition that mimics a heart attack

As researchers have begun to better understand the biological differences in the circulatory systems of men and women, they have learned that women can have a host of other cardiac problems that can mimic a heart attack.

For instance, women are more likely to have dissections, or tears, in their coronary arteries, which carry similar symptoms to a heart attack, says Michelle O'Donoghue, a cardiologist at Brigham and Women's Hospital and associate professor of medicine at Harvard Medical School in Boston. They're also more likely to get inflammation of the heart, known as myocarditis.

Another type of heart disease that affects women more than men is microvascular disease. Women have smaller hearts and blood vessels than men, and when their smaller vessels get clogged with plaque, blood flow is compromised, causing them to feel like they are having a heart attack.


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Although Bairey Merz and her colleagues discovered microvascular dysfunction a few decades ago, in November she published two studies in JAMA. The studies offer recommendations about who should be tested for microvascular dysfunction and which tools work best to help diagnose the condition, which can often be managed with medications. Noninvasive imaging studies called positron emission tomography (PET) or cardiac magnetic resonance imaging (cardiac MRI) can detect the condition, as well as a more invasive coronary angiogram where doctors look inside the blood vessels to see if they are blocked.

Women get a glimpse of their future heart health in pregnancy

The onset of diabetes or sudden hypertension and fluid retention during pregnancy, called preeclampsia, are powerful predictors of a woman's future risk of heart disease. For women, the conditions are a potentially useful red flag of potential cardiovascular trouble ahead.

A study of 58,671 pregnant women, published last August in the Annals of Internal Medicine, found that women who developed hypertension and/or gestational diabetes during their first pregnancy developed chronic hypertension at two to three times the rate of women who didn't show these problems during pregnancy. The women also developed a 70 percent higher rate of type 2 diabetes and a 30 percent higher rate of high cholesterol.

If a woman develops one or both of these adverse pregnancy outcomes, they should check their blood pressure every year and see an internist or cardiologist to manage their health within five years of the pregnancy, notes Bairey Merz.

Women may need to watch their blood pressure at earlier ages than men need to

Susan Cheng, M.D., director of public health research at the Smidt Heart Institute at Cedars-Sinai and coauthor of a study published last month in JAMA Cardiology , says that hypertension “is the number one risk factor for any type of major cardiovascular disease.” Hypertension can lead to stroke, heart failure or a heart attack.

After analyzing sex-specific patient blood pressures over the span of 43 years from four community-based health studies across the U.S., Cheng and her research team found that a woman's blood pressure rises earlier in life, and faster, than a man's blood pressure.

So “younger women need to be really on top of their blood pressure. If they don't keep an eye on it, by the time they're older, women are more likely to develop certain types of heart disease, such as a type of heart failure,” she says.

"Our data would suggest that women may need to have a different threshold of blood pressure than what is currently recommended,” notes Cheng.

Women appear to recover differently from a heart attack, though the picture is in no way complete

In October, Michael Nanna, a cardiovascular disease fellow at Duke University School of Medicine, published a study that analyzed data from over 3,000 patients ages 75 and older, following hospitalization for things like heart attack. Their results showed that women had lower rates of obstructive coronary disease and less need for stents than men. However, women had higher rates of bleeding complications after a coronary angioplasty, a procedure that opens narrowed blood vessels. And overall, after such hospitalizations, women experienced greater impacts to things like their mobility and ability to perform daily tasks than men did. “We can do a better job recognizing these impairments and do therapy to address them,” Nanna says.

Another study published last December in the Journal of the American College of Cardiology found that, contrary to popular belief, women do not have overall worse outcomes than men after a heart attack, says study coauthor O'Donoghue of Brigham and Women's Hospital.

She and her team analyzed outcome data on 68,730 male and female patients within 30 days of hospitalization for chest pain or a special type of heart attack. “When we took into account that women tend to be older than men and have more comorbid conditions when they get a heart attack, they're not at higher risk of a bad outcome,” she says.

Of course, there are exceptions. O'Donoghue says older women do worse than men after a special type of heart attack associated with the sudden rupture of plaque inside the coronary artery.

Why Aren't Women Taking Their Statins?

Michael Nanna, a cardiovascular disease fellow at Duke University School of Medicine in North Carolina, says that women at risk for cardiovascular disease don't receive aggressive cholesterol-lowering drugs called statins.

In a study published in Circulation: Cardiovascular Quality and Outcomes, Nanna and his colleagues examined the use of statin therapy among 5,693 patients with, or at risk for, atherosclerotic cardiovascular disease. They found that 67 percent of the women versus 78 percent of the men received a statin.

The most common reason eligible women are not on statin treatment? Their providers never offered them one.

Also, more women than men declined statin therapy because they didn't feel they were safe and effective. Women were also 7.9 percent more likely to report discontinuing their statin because of a side effect compared with 3.6 percent of men. However, the potential side effects of statins, which can include muscle aches, tenderness or weakness, are considered low, notes Nanna. The side effects reported may be related to a “nocebo effect,” where negative expectations about a treatment leads to a negative effect.

"This is just one piece of a larger puzzle of suboptimal treatment seen in women,” says Nanna.

"Closing the treatment gap requires all of us to maintain consistency in the care we provide in clinical settings,” says Nanna. “We need to rededicate ourselves to teaching the safety of statins and their use in reducing cardiovascular risk."

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